Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration.

OBJECTIVE: The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature. BACKGROUND: Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved. METHOD: We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes. RESULTS: We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting. CONCLUSIONS: Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance. APPLICATION: Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.

Neurological Morbidity and Mortality in a Neurological Low-Resource Setting: A 2-Year Audit of a Nigerian Hospital.

BACKGROUND: There is still a paucity of information on the burden of neurological disorders particularly in low-resource settings such as sub-Saharan Africa. The objective of this study was to report the burden of neurological disorders, including morbidity and mortality, in adult patients at a Northwestern Nigerian tertiary hospital over a 2-year period. MATERIALS AND METHODS: An audit of adult medical admissions from July 1, 2015, to June 30, 2017, was conducted. Anonymized data on medical admissions were retrieved from admission registries. Primary and secondary outcomes of interest were neurological diagnoses and clinical outcomes, respectively. The Pearson χ and independent t tests were used to test for differences between neurological and general medical proportions and outcomes with a 5% significance level set. RESULTS: Over the 2-year period, 2772 adults were admitted. Neurological morbidity comprised almost a 10th of all adult medical admissions (9.1%), whereas neurological mortality accounted for more than a fifth of all deaths (22.2%). Stroke was the leading cause of neurological morbidity (62.9%) and mortality (79.8%). Infections of the nervous system and epilepsy were other frequent causes of neurological morbidity. Outcomes were poorer for neurological patients (fatality rates: neurological, 55.5%; medical, 19.5%, P<0.001). CONCLUSIONS: Neurological disorders were a significant cause of adult medical morbidity and, to a greater extent, of mortality. Cerebrovascular disease and infections of the nervous system were major drivers of mortality. Cost-effective strategies appropriate for low-resource settings are required to prevent and reverse these negative outcomes.

The landscape of psoriasis provision in the UK.

Psoriasis remains one of the commonest conditions seen in dermatological practice, and its treatment is one of the greatest cost burdens for the UK National Health Service. Treatment of psoriasis is complex, with numerous overlapping lines and therapies used in combination. This complexity reflects the underlying pathophysiology of the disease as well as the heterogeneous population that it affects. National Institute for Health and Care Excellence (NICE) guidance for the treatment of psoriasis has been available since 2013, and has been the subject of three national audits conducted by the British Association of Dermatologists. This report synthesizes the results of the most recent of those exercises and places it in the context of the NICE guidance and previous audits. It clearly shows the significant burden of disease, issues with provision of services and long waiting times and the marked shift in therapies towards targeted biologic therapies.

Accuracy of medical billing data against the electronic health record in the measurement of colorectal cancer screening rates.

OBJECTIVE: Medical billing data are an attractive source of secondary analysis because of their ease of use and potential to answer population-health questions with statistical power. Although these datasets have known susceptibilities to biases, the degree to which they can distort the assessment of quality measures such as colorectal cancer screening rates are not widely appreciated, nor are their causes and possible solutions. METHODS: Using a billing code database derived from our institution's electronic health records, we estimated the colorectal cancer screening rate of average-risk patients aged 50-74 years seen in primary care or gastroenterology clinic in 2016-2017. 200 records (150 unscreened, 50 screened) were sampled to quantify the accuracy against manual review. RESULTS: Out of 4611 patients, an analysis of billing data suggested a 61% screening rate, an estimate that matches the estimate by the Centers for Disease Control. Manual review revealed a positive predictive value of 96% (86%-100%), negative predictive value of 21% (15%-29%) and a corrected screening rate of 85% (81%-90%). Most false negatives occurred due to examinations performed outside the scope of the database-both within and outside of our institution-but 21% of false negatives fell within the database's scope. False positives occurred due to incomplete examinations and inadequate bowel preparation. Reasons for screening failure include ordered but incomplete examinations (48%), lack of or incorrect documentation by primary care (29%) including incorrect screening intervals (13%) and patients declining screening (13%). CONCLUSIONS: Billing databases are prone to substantial bias that may go undetected even in the presence of confirmatory external estimates. Caution is recommended when performing population-level inference from these data. We propose several solutions to improve the use of these data for the assessment of healthcare quality.

A medicolegal analysis of malpractice claims involving anesthesiologists in the gastrointestinal endoscopy suite (2007-2016).

STUDY OBJECTIVE: Gastrointestinal endoscopy cases make up the largest portion of out of operating room malpractice claims involving anesthesiologists. To date, there has been no closed claims analysis specifically focusing on the claims from the endoscopy suite. We aim to identify associated case characteristics and contributing factors. DESIGN: Retrospective review of closed claims. SETTING: Multi-institutional setting of hospitals that submit data to the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System, a database representing approximately 30% of annual malpractice cases in the United States. PATIENTS: A total of 58 claims in the gastrointestinal endoscopy suite between January 1, 2007 and December 31, 2016. INTERVENTIONS: Gastrointestinal endoscopy procedures. MEASUREMENTS: We analyzed associated factors for each case as well as payments, and severity scores. MAIN RESULTS: There was a difference in the percent of cases that resulted in payment by procedure type, with 91% of endoscopic retrograde cholangiopancreatography (ERCP) cases resulting in payment compared with 37.5% of colonoscopy cases, 25% of combined esophagogastroduodenoscopy (EGD)/colonoscopy cases, 21.4% of EGD cases and 0.0% of endoscopic ultrasound cases (P = 0.0008). Oversedation was a possible contributing factor in 62.5% of cases. The mean payment for all claims involving anesthesiologists in the endoscopy suite was $99,754. CONCLUSIONS: There are differences in the rates of payment of malpractice claims between procedures. ERCPs made up a disproportionate percentage of the total amount paid to patients. While a significant percent of cases involved possible oversedation, these errors were compounded by other factors, such as failure to resuscitate or recognize the acute clinical change. With medically complex patients undergoing endoscopic procedures, it is critical to have well prepared anesthesia providers.

Multimorbidity and survival for patients with acute myocardial infarction in England and Wales: Latent class analysis of a nationwide population-based cohort.

BACKGROUND: There is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI. METHODS AND FINDINGS: This national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; ß-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population. CONCLUSIONS: Multimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03037255.

Semi-Automatic Electronic Stent Register: a novel approach to preventing ureteric stents lost to follow up.

BACKGROUND: Ureteric stents are indispensable tools in modern urology; however, the risk of them not being followed-up once inserted poses medical and medico-legal risks. Stent registers are a common solution to mitigate this risk; however, manual registers are logistically challenging, especially for busy units. METHODS: Western Sydney Local Health District developed a novel Semi-Automatic Electronic Stent Register (SAESR) utilizing billing information to track stent insertions. To determine the utility of this system, an audit was conducted comparing the 6 months before the introduction of the register to the first 6 months of the register. RESULTS: In the first 6 months of the register, 457 stents were inserted. At the time of writing, two of these are severely delayed for removal, representing a rate of 0.4%. In the 6 months immediately preceding the introduction of the register, 497 stents were inserted, and six were either missed completely or severely delayed in their removal, representing a rate of 1.2%. A non-inferiority analysis found this to be no worse than the results achieved before the introduction of the register. CONCLUSION: The SAESR allowed us to improve upon our better than expected rate of stents lost to follow up or severely delayed. We demonstrated non-inferiority in the rate of lost or severely delayed stents, and a number of other advantages including savings in personnel costs. The semi-automatic register represents an effective way of reducing the risk associated with a common urological procedure. We believe that this methodology could be implemented elsewhere.

Can preventive care activities in general practice be sustained when financial incentives and external audit plus feedback are removed? ACCEPt-able: a cluster randomised controlled trial protocol.

BACKGROUND: Financial incentives and audit plus feedback on performance are two strategies commonly used by governments to motivate general practitioners (GP) to undertake specific healthcare activities. However, in recent years, governments have reduced or removed incentive payments without evidence of the potential impact on GP behaviour and patient outcomes. This trial (known as ACCEPt-able) aims to determine whether preventive care activities in general practice are sustained when financial incentives and/or external audit plus feedback on preventive care activities are removed. The activity investigated is annual chlamydia testing for 16- to 29-year-old adults, a key preventive health strategy within this age group. METHODS/DESIGN: ACCEPt-able builds on a large cluster randomised controlled trial (RCT) that evaluated a 3-year chlamydia testing intervention in general practice. GPs were provided with a support package to facilitate annual chlamydia testing of all sexually active 16- to 29-year-old patients. This package included financial incentive payments to the GP for each chlamydia test conducted and external audit plus feedback on each GP's chlamydia testing rates. ACCEPt-able is a factorial cluster RCT in which general practices are randomised to one of four groups: (i) removal of audit plus feedback-continue to receive financial incentive payments for each chlamydia test; (ii) removal of financial incentive payments-continue to receive audit plus feedback; (iii) removal of financial incentive payments and audit plus feedback; and (iv) continue financial incentive payments and audit plus feedback. The primary outcome is chlamydia testing rate measured as the proportion of sexually active 16- to 29-year-olds who have a GP consultation within a 12-month period and at least one chlamydia test. DISCUSSION: This will be the first RCT to examine the impact of removal of financial incentive payments and audit plus feedback on the chlamydia testing behaviour of GPs. This trial is particularly timely and will increase our understanding about the impact of financial incentives and audit plus feedback on GP behaviour when governments are looking for opportunities to control healthcare budgets and maximise clinical outcomes for money spent. The results of this trial will have implications for supporting preventive health measures beyond the content area of chlamydia. TRIAL REGISTRATION: The trial has been registered on the Australian and New Zealand Clinical Trials Registry ( ACTRN12614000595617 ).

Meeting The Joint Commission's Dose Incident Identification and External Benchmarking Requirements Using the ACR's Dose Index Registry.

PURPOSE: The purpose of this investigation was to evaluate the potential of using the ACR's Dose Index Registry(®) to meet The Joint Commission's requirements to identify incidents in which the radiation dose index from diagnostic CT examinations exceeded the protocol's expected dose index range. METHODS: In total, 10,970 records in the Dose Index Registry were statistically analyzed to establish both an upper and lower expected dose index for each protocol. All 2015 studies to date were then retrospectively reviewed to identify examinations whose total examination dose index exceeded the protocol's defined upper threshold. Each dose incident was then logged and reviewed per the new Joint Commission requirements. CONCLUSIONS: Facilities may leverage their participation in the ACR's Dose Index Registry to fully meet The Joint Commission's dose incident identification review and external benchmarking requirements.

Improving clinical outcomes through centralization of rectal cancer surgery and clinical audit: a mixed-methods assessment.

BACKGROUND: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective. METHODS: A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September-December 2014, with healthcare professionals, managers and experts. RESULTS: From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level. CONCLUSION: The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to strengthen the centralization strategy.

Healthcare Databases in Thailand and Japan: Potential Sources for Health Technology Assessment Research.

BACKGROUND: Health technology assessment (HTA) has been continuously used for value-based healthcare decisions over the last decade. Healthcare databases represent an important source of information for HTA, which has seen a surge in use in Western countries. Although HTA agencies have been established in Asia-Pacific region, application and understanding of healthcare databases for HTA is rather limited. Thus, we reviewed existing databases to assess their potential for HTA in Thailand where HTA has been used officially and Japan where HTA is going to be officially introduced. METHOD: Existing healthcare databases in Thailand and Japan were compiled and reviewed. Databases' characteristics e.g. name of database, host, scope/objective, time/sample size, design, data collection method, population/sample, and variables were described. Databases were assessed for its potential HTA use in terms of safety/efficacy/effectiveness, social/ethical, organization/professional, economic, and epidemiological domains. Request route for each database was also provided. RESULTS: Forty databases- 20 from Thailand and 20 from Japan-were included. These comprised of national censuses, surveys, registries, administrative data, and claimed databases. All databases were potentially used for epidemiological studies. In addition, data on mortality, morbidity, disability, adverse events, quality of life, service/technology utilization, length of stay, and economics were also found in some databases. However, access to patient-level data was limited since information about the databases was not available on public sources. CONCLUSION: Our findings have shown that existing databases provided valuable information for HTA research with limitation on accessibility. Mutual dialogue on healthcare database development and usage for HTA among Asia-Pacific region is needed.

Review of critical incidents in a university department of anaesthesia.

In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.

Geriatric assessment of older patients with cancer in Australia--a multicentre audit.

OBJECTIVE: The aim of this study is to determine the frequency of geriatric assessment in patients aged over 70 years in Australian medical oncology clinics. MATERIAL AND METHODS: This was a multicentre audit in two parts: a retrospective file review of initial consultations with an oncologist and prospective audit of case presentations at multidisciplinary meetings (MDMs). Patients aged over 70 years presenting to a medical oncology clinic or being discussed at an MDM were eligible. Data was collected at six oncology centres in Victoria, NSW and Canberra from October 2009 to March 2010. RESULTS: Data was collected from 251 file reviews and 108 MDM discussions in a total of 304 patients. Median age was 76 years (range 70-95). The geriatric assessment (GA) domains most frequently assessed during an initial consultation were the presence of comorbidities (92%), social situation-living alone or with someone (80%), social supports (63%), any mention of at least one Activity of Daily Living (ADL) (50%) and performance status (49%). Less frequently assessed were any Instrumental Activity of Daily Living (IADL) (26%), presence of a geriatric syndrome (24%), polypharmacy (29%) and creatinine clearance (11%). Only one patient had all components of ADLs and IADLs assessed. During MDMs all the geriatric domains were comparatively less frequently assessed. No patients had all ADL and IADL components discussed formally in an MDM. CONCLUSION: This is the first multicentre audit that reveals the low rates of GA in Australian medical oncology practice and describes the GA domains considered important by oncology clinicians.

Evaluating Aboriginal and Torres Strait Islander health promotion activities using audit and feedback.

Indigenous primary health care (PHC) services have been identified as exemplary models of comprehensive PHC; however, many practitioners in these services struggle to deliver effective health promotion. In particular, practitioners have limited capacity and resources to evaluate health promotion activities. Best practice health promotion is important to help address the lifestyle and wider factors that impact on the health of people and communities. In this paper, we report on the acceptability and feasibility of an innovative approach for evaluating the design of health promotion activities in four Indigenous PHC services in the Northern Territory. The approach draws on a popular continuous quality improvement technique known as audit and feedback (A&F), in which information related to best practice is gathered through the use of a standardised audit tool and fed back to practitioners. The A&F approach has been used successfully to improve clinical service delivery in Indigenous PHC; however, the technique has had limited use in health promotion. The present study found that facilitated participatory processes were important for the collection of locally relevant information and for contributing to improving PHC practitioners' knowledge and understanding of best practice health promotion.

Formative assessment based on an audit and feedback improves nuchal translucency ultrasound image quality.

OBJECTIVES: The purpose of this work was to study the impact of an audit and feedback on the quality of routine first-trimester nuchal transparency ultrasound images. METHODS: Eighty-eight sonographers were each sent 2 different series of 30 consecutive nuchal translucency images at a mean interval of 3 months to a dedicated, protected server for remote double-blind independent analysis based on the new Collège Français d'Echographie Foetale/Centre National de la Recherche Scientifique image-scoring method (https://www.cfef.org/evaluation/ISMCFEFCNRS.pdf). The sonographers were classified as low (score below the median) or high (score above the median) scorers for each series. Before their second evaluation, 73 of the 88 sonographers received a feedback report on their first series of images, whereas the other 15 participants received no feedback. The baseline characteristics of the participants who did and did not receive feedback were comparable. RESULTS: Participants who received feedback increased their average score significantly, from a mean ± SD of 11.1 ± 1.3 to 13.4 ± 1.4 among low scorers (P < .00001) and from 15.1 ± 1.2 to 16.0 ± 1.4 among high scorers (P < .001), whereas no significant change was seen among participants who received no feedback (low scorers, 10.9 ± 1.5 to 12.1 ± 2.0; P = .11; high scorers, 14.7 ± 1.3 to 14.6 ± 1.3; P = .99). The proportion of satisfactory images increased by 48% among low scorers who received feedback. CONCLUSIONS: Formative assessment based on a moderately intensive audit and feedback is feasible and effective for improving the quality of routine first-trimester nuchal transparency ultrasound images.

The impact of local guidelines on the tumour marker requesting patterns of a General Surgery Department.

BACKGROUND: The inappropriate use of tumour markers (TMs) is a common problem. The aim of this audit was to evaluate the impact of local guidelines on the TM requesting patterns of a General Surgery Department. METHODS: CA 125, CA 19-9, CA15-3, CEA, AFP and HCG requests from all hospital surgical locations were audited over two periods of eight months before and after the implementation of local requesting guidelines. RESULTS: Postintervention, total TM requests decreased by 32% while patient requests decreased by 9.8%. Single TM requesting increased and requests for panels containing four or more TMs decreased from 279 to 60 requests (78% reduction). CONCLUSION: Interdepartmental collaboration and the implementation of local guidelines have resulted in a change in requesting behaviour, most notably a reduction in multiple TM panel requests.

Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database.

We designed and internally validated an aggregate weighted early warning scoring system specific to the obstetric population that has the potential for use in the ward environment. Direct obstetric admissions from the Intensive Care National Audit and Research Centre's Case Mix Programme Database were randomly allocated to model development (n = 2240) or validation (n = 2200) sets. Physiological variables collected during the first 24 h of critical care admission were analysed. Logistic regression analysis for mortality in the model development set was initially used to create a statistically based early warning score. The statistical score was then modified to create a clinically acceptable early warning score. Important features of this clinical obstetric early warning score are that the variables are weighted according to their statistical importance, a surrogate for the FI O2 /Pa O2 relationship is included, conscious level is assessed using a simplified alert/not alert variable, and the score, trigger thresholds and response are consistent with the new non-obstetric National Early Warning Score system. The statistical and clinical early warning scores were internally validated using the validation set. The area under the receiver operating characteristic curve was 0.995 (95% CI 0.992-0.998) for the statistical score and 0.957 (95% CI 0.923-0.991) for the clinical score. Pre-existing empirically designed early warning scores were also validated in the same way for comparison. The area under the receiver operating characteristic curve was 0.955 (95% CI 0.922-0.988) for Swanton et al.'s Modified Early Obstetric Warning System, 0.937 (95% CI 0.884-0.991) for the obstetric early warning score suggested in the 2003-2005 Report on Confidential Enquiries into Maternal Deaths in the UK, and 0.973 (95% CI 0.957-0.989) for the non-obstetric National Early Warning Score. This highlights that the new clinical obstetric early warning score has an excellent ability to discriminate survivors from non-survivors in this critical care data set. Further work is needed to validate our new clinical early warning score externally in the obstetric ward environment.